Healthcare Provider Details

I. General information

NPI: 1154242675
Provider Name (Legal Business Name): BUENA VISTA PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 MONTGOMERY BLVD NE # 1141
ALBUQUERQUE NM
87111-3501
US

IV. Provider business mailing address

9701 MONTGOMERY BLVD NE # 1141
ALBUQUERQUE NM
87111-3501
US

V. Phone/Fax

Practice location:
  • Phone: 512-406-1157
  • Fax:
Mailing address:
  • Phone: 512-406-1157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHNNIE DALEY
Title or Position: OWNER
Credential:
Phone: 512-406-1157